Provider Demographics
NPI:1366504540
Name:MITCHAM, KATHLEEN J (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:MITCHAM
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 CLINIC RD E
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:MT
Mailing Address - Zip Code:59521-8826
Mailing Address - Country:US
Mailing Address - Phone:406-395-4486
Mailing Address - Fax:406-395-5850
Practice Address - Street 1:535 CLINIC RD E
Practice Address - Street 2:
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521-8826
Practice Address - Country:US
Practice Address - Phone:406-395-4486
Practice Address - Fax:406-395-5850
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001462363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAR66288Medicare UPIN
AKR66288Medicare UPIN